Intensely Local: How Some Rural Hospitals Thrive

Under myriad pressures, an increasing number of rural hospitals are either shutting their doors or joining up with large systems. Some, though, continue to do quite well as independents.

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Dawn Langley moved to eastern North Carolina’s rural Robeson County 27 years ago to teach and coach at the University of North Carolina-Pembroke. She fell in love with the community and determined to help make it a healthier one.

So she applied for and received a National Health Service Corps scholarship, attended Wake Forest University’s Bowman Gray School of Medicine and is now a physician assistant at Southeastern Health’s primary care clinic in the 2-square-mile town of Maxton.

“Here I am,” she said on a busily relaxed Thursday afternoon before sitting down with Louise Cummings, 75, a longtime patient, “and I wouldn’t be anywhere else.”

Not every would-be rural practitioner has that choice. Scores of rural hospitals around the country have closed in the last six years, but Southeastern Health’s 452-bed main facility and 30 primary care and specialty clinics remain open. That gives Langley the ability to focus on local care.

“That’s a good girl over there,” she says of her doc. “I love to come here because I love her. She’s good to me.”

Downtown Maxton, North Carolina.

Robeson County was in need of some loving when Langley arrived, and can still use all it can get. The county has the highest poverty rate in the state, among the highest in the country, with one in three residents living below the federal poverty level of $24,300 for a family of four.

Heart disease, obesity and cancer rates are high; life expectancy is low.

Louis Cummings’ son Robby, who always accompanies his mom on her appointments, said Langley has improved his mother’s overall health – lowering her blood sugar, for example – by taking the time to get to know her, her habits and her customs.

“We fixed her get-up-and-go,” Langley said. “It was busted.”

Joann Anderson is Southeastern Health’s CEO and a former chair of the American Hospital Association’s Small or Rural Hospital Governing Council. Though Southeastern has but one hospital, Anderson said it offers everything a multi-hospital system does.

Robeson County is roughly 40 percent Native American, 30 percent white and 25 percent black, with a growing Latino population. Southeastern takes pride in its familiarity with this diverse population, and prefers, at least for now, to remain locally focused and independent.

“We believe we have the vested interests of the population in hand,” Anderson said. “And that might be lost if we connected with a larger institution.”

Doing what they’re doing

King’s Daughters Medical Center, in the southern Mississippi town of Brookhaven, has likewise chosen to keep it local.

Not that they haven’t considered joining a system.

“It’s something we talk about, because you have to,” said Alvin Hoover, the 99-bed hospital’s CEO and, like Anderson, a past chair of the AHA’s Small or Rural Hospital Governing Council. “But we’ve felt like we can be successful doing the things we’re doing. And we have been.”

King’s Daughters has won numerous awards in recent years, for quality, patient experience and best places to work. It was among 251 hospitals awarded five stars in 2015 by the Centers for Medicare & Medicaid Services for patient experience.

Hoover acknowledges there have been bumps in the road. In 2008, the hospital laid off 17 employees and cut everyone else’s hours.

“That was tough,” Hoover admitted, but the hospital turned a 5 percent operating loss into a gain.

The challenges to viability are many. According to the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, 78 rural hospitals have shut down since January 2010. Fifty-one of those were in the South.

Many rural communities have declining, aging populations, and rural hospitals receive a higher percentage of patients with no health coverage than their urban counterparts. They also tend to operate on tighter margins– tighter still in the aftermath of the March 2013 federal sequestration.

Further cuts came when the federal government reduced the bad-debt reimbursement Medicare pays to hospitals for shouldering much of the cost of care for those who can’t afford it. This was done with the assumption that Medicaid expansion would help offset the lost revenue – which might at least partially explain so many closures in the South.

Nineteen states have chosen not to expand Medicaid, 10 of them in the South. Mark Holmes, director of UNC’s Sheps Center, said there’s a lot of overlap in the map of where hospitals have closed and of states that haven’t expanded Medicaid.

But, he cautioned, “I think it’ll be awhile before we can know for sure” the extent to which the closures can be directly attributed to decisions not to expand Medicaid.

Homegrown

In October 2014, King’s Daughters celebrated 100 years in Lincoln County.

“There’s a tremendous sense of ownership among the folks in this community that they started this hospital and they helped it grow,” Hoover said. “These folks feel like this is their hospital. I’m humbled when I talk with them that they love this hospital like they do.

“It’s an awesome feeling for me.”

Holmes said that a hospital is commonly one of the two largest employers in rural counties. King’s Daughters employs about 650 people in a county with an unemployment rate about 15 percent higher than the national average.

But, he added, rural hospitals are also economic-development drivers.

When a manufacturer is scouting new locations, “they’re going to want the things they value, and included in that would be a hospital,” Holmes said. “I think that aspect sometimes gets lost when we talk about closures and their impact on rural communities.”

When King’s Daughters was struggling, Hoover said, “We didn’t want to let our community down. So we’ve clawed our way back to success.”

Hoover said King’s Daughters continues to cultivate relationships with other hospitals and providers. They partner, for example, for telemedicine, including telestroke in the ER and telepulmonology.

Provide what’s most needed in your community, and what makes the most business sense, Hoover advised, and work with partners to offer the rest.

And like Joann Anderson, he considers his hospital to be a system unto itself.

“We’re reaching out in ways that we can afford to, trying to better lives and help our hospital stay strong,” he said. A fitness center and a therapy clinic sit right outside the hospital doors. “Things look a lot different than they did 10 years ago.”

Central to maintaining the commitment to Lincoln County, Hoover said, is recruiting health care professionals with local connections.

Standing in a hospital hallway lined with photos of staff members, he describes a local connection for the majority – local boy meets girl in med school, they opt to settle in Brookhaven, then encourage classmates to join them – and that gallery includes quite a few young faces.

Hoover’s recruited 16 physicians alone through word-of-mouth.

Nowhere else

For Southeastern Health in North Carolina, viability entails maintaining a presence throughout a geographically large county where many can’t afford transportation. It involves nurturing relationships with neighbors.

Which certainly helps in an event like a natural disaster, as when Hurricane Matthew hit Robeson County in October.

Though its clinics had to shut down, the main hospital remained open. Southeastern providers hunkered down there, working in rounds, eating and sleeping on-site; others set up practice in shelters.

“Everybody pulled together and really worked as a team to ensure, first of all, patient safety and care,” Britt said, “and then in just supporting one another – emotional support, because a lot of our employees lost everything.

“We’ve had a slogan in the past, ‘It’s neighbors caring for neighbors.’ I really think, in this situation, that’s what happened here.”

That spirit carries over to the everyday, particularly in Southeastern’s primary care clinics, where patients, many of whom are assigned case managers, are offered help with transportation, medication compliance – whatever’s needed, including some sound advice on healthy living.

Dawn Langley, for example, talks with many of her patients about “that Sunday meal – we call it country food around here.”

“‘You can have a little country food,” Langley tells folks, “‘but you gotta get out and walk a little bit.’ I tell them to have a little country food, but we gotta cut back; gotta understand about carbohydrates.”

She encourages them to acknowledge issues early, before they require hospitalization. “Staying home is a good thing,” she advises. “That’s the only place you can go to get well.”

Does she see results on a day-to-day basis?

“I’d say, ‘Wimpy don’t apply.’ If you come here, you better know what you’re in for, right?” Langley said. “In the short term, you get those glimmers of light here and there – enough to keep you going. But you’ve got to be in it for the long haul. You have to be committed.”

Louise Cummings says she’s feeling pretty good. “I used to be so sick I couldn’t hold my head up.” Her son Robby confirms that.